Sudden onset of a periorbital rash, usually pruritic, and/or eyelid swelling.

• Varicella zoster virus (shingles): Dermatomal pattern with severe pain. See 4.16, HERPES ZOSTER OPHTHALMICUS/VARICELLA ZOSTER VIRUS.
• Eczema: Recurrent in nature and is markedly pruritic.
• Impetigo: Pruritic with honey-colored crusts.
• Orbital cellulitis or preseptal cellulitis: See 7.3.1, ORBITAL CELLULITIS and 6.10, PRESEPTAL CELLULITIS.

Most commonly eye drops and cosmetics.

1. Avoid the offending agent(s).
2. Cool compresses four to six times per day.
3. Preservative-free artificial tears four to eight times per day and topical antihistamines (e.g., levocabastine 0.05% q.i.d.).
4. Consider tacrolimus 0.03% to 0.1% q.h.s. or b.i.d. (preferred).
5. Consider a mild steroid ointment (e.g., fluorometholone 0.1%, or loteprednol 0.5%) applied to the periocular area b.i.d. to t.i.d. for 4 to 5 days for skin involvement.
6. Consider an oral antihistamine (e.g., diphenhydramine 25 to 50 mg p.o. t.i.d. to q.i.d.) for several days.

Re-examine within 1 week.